Basics of XE, XP, XS and XU modifier

Modifiers change the payment definition of CPT procedure code. Yes, modifiers define the procedure  in different ways like whether the procedure was really necessary to perform, the procedure was done completely or not, the procedure was done using assistant surgeons, additional or multiple procedure performed etc. There is a big list of modifiers used along with CPT codes. But, today we will talk only about the 59 modifier or XE, XP, XS, XU modifier. 

There are modifier indicators which tells us whether the two codes can be coded together or not. Here we have to follow the Correct Coding Modifier Indicator (CCMI) for coding two or more CPT codes together.

‘0′ – The CPT codes should never be reported together by the same provider for the same beneficiary on the same date of service

‘1’ – The CPT codes may be reported together only in defined circumstances, which are identified on the claim by the use of specific NCCI-associated modifiers.

The main function of these edits is to prevent or remove unnecessary or overlapping services. Use of 59 modifier has been done very incorrectly in past. Hence it is very important to learn in and out about this modifier and X modifiers. Let us learn about them one by one.

Read also: When to use Hospice Modifiers

Use of XE modifier

MODIFIER XE – SEPARATE ENCOUNTER, A SERVICE THAT IS DISTINCT BECAUSE IT OCCURRED DURING A SEPARATE ENCOUNTER

Modifier -XE is a subset of modifier -59. It is used to indicate a procedure should be reported separately with another procedure that it would typically bundle into because it was performed in a separate encounter. Modifier -76 is used if the same procedure code is reported. Modifier -XE is used when a procedure is performed that is an NCCI edit with a procedure performed in a different session (a different CPT code). Below example with help in using XE modifier.

Arthroscopic treatment of structures in adjoining areas of the same shoulder constitutes treatment of a single anatomic site.

29827 – Arthroscopy, shoulder, surgical; with rotator cuff repair

29820 – Arthroscopy, shoulder, surgical; synovectomy, partial

Modifier 59 should not be reported with 29820 if both procedures are performed on the same shoulder during the same operative session because the shoulder joint is a single anatomic structure.

If the procedures were performed on different shoulders, modifiers RT and LT should be used.

Modifier 59 may be reported when the procedures are performed in different encounters on the same day. For different encounters XE can be assigned to CPT code 29820 to bypass the edits.

Read also: When to use PI and PS modifiers in PET scan

Use of XP modifier

MODIFIER XP – SEPARATE PRACTITIONER, A SERVICE THAT IS DISTINCT BECAUSE IT WAS PERFORMED BY A DIFFERENT PRACTITIONER

Modifier -XP is a subset of modifier -59. It is used to indicate a procedure should be reported separately with another procedure that it would typically bundle into because it was performed by a different practitioner (physician, nurse practitioner, etc.). One MAC (WPS) has stated that this modifier is used when two physicians with the same specialty in the same group practice perform procedures subject to NCCI edits.

Read also: How to become expert in using Modifier 25 and 27

Use of XS modifier

MODIFIER XS – SEPARATE STRUCTURE, A SERVICE THAT IS DISTINCT BECAUSE IT WAS PERFORMED ON A SEPARATE ORGAN/STRUCTURE

Modifier -XS is a subset of modifier -59. It is used to indicate a procedure should be reported separately with another procedure that it would typically bundle into because it was performed on a separate site. It may be used to bypass NCCI edits for procedures such as selective catheter placements in different vascular families, angioplasty in one vessel and stent placement in another vessel, intracranial angiography on one side and cervical carotid angiography on the other side, etc. Modifiers -LT and -RT may also explain the relationship between the codes and bypass an edit. Let use learn using XS modifier by below example.

11055 – Paring or cutting of benign hyperkeratotic lesion (e.g., corn or callus); single lesion

11720 – Debridement of nail(s) by any method(s); 1 to 5

Modifier 59 should not be reported with 11720 if a nail is debrided on the same toe from which a hyperkeratotic lesion has been removed.

Modifier 59 may be reported with 11720 if multiple nails are debrided and a corn that is on the same foot and that is not adjacent to a debrided toenail is pared. Use of XS should be perfect in this scenario with CPT code 11720.

Read also: When to use 58, 78 and 79 Modifiers with CPT codes

Use of XU modifier

MODIFIER XU – UNUSUAL NON-OVERLAPPING SERVICE THAT IS DISTINCT BECAUSE IT DOES NOT OVERLAP USUAL COMPONENTS OF THE MAIN SERVICE

Modifier -XU is a subset of modifier -59. It can be used to indicate a diagnostic procedure was distinct from an interventional procedure on the same date of service, if it is not a repeat or guiding study. Below example will give clear picture about using XU modifier.

47370 – Laparoscopy, surgical, ablation of 1 or more liver tumor(s); radiofrequency

76942 – Ultrasonic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device), imaging supervision and interpretation

Modifier 59 should not be reported with 76942 if the ultrasonic guidance is for needle placement for the laparoscopic liver tumor ablation procedure.

Modifier 59 may be reported with 76942 if the ultrasonic guidance for needle placement is unrelated to the laparoscopic liver tumor ablation procedure. Hence, use of XU modifier is perfect here with CPT code 76942 for bypassing the CCI edit.

Modifier 59 may be reported with 11100 if the procedures are performed at different anatomic sites on the same side of the body and a specific anatomic modifier does not apply.

Appropriate use of modifiers XE, XP, XS, XU, or 59:

Separate surgical operative session on the same date of service (e.g. 8 AM surgery with one procedure, 4 PM surgery with second procedure code). 

Modifier to use: XU Modifier

Rationale XE Separate encounter.

Like modifier 59, modifier XP should not be appended to an E/M service procedure code; this is not a valid or appropriate procedure/modifier combination. Modifiers -24 or -25 should be used as appropriate instead.

Modifier to use: XP

Rationale : Modifier XP could be used if a cross-provider bundling scenario would apply (not TC/26 bundling), the providers are of different specialties, and the billing office can support that the cross-provider bundling should not apply in this case. No example can be given as this is very uncommon.
Modifier XP should not be appended to E/M service codes.

Injection into tendon sheath, right ankle (20550) and injection into tendon sheath, left ankle (20550-XS).

Modifier to use: XS

Rationale : Same encounter
 Different anatomical site and
contralateral structure.
 (Note: 20550 is not eligible
for modifiers LT or RT.)

Separate injury (or area of injury in extensive injuries).

Modifier to use: XS versus 59

Rationale : Depending upon your specific circumstances XS or 59 may be most appropriate.

A diagnostic procedure is performed. Due to the findings, a decision is then made to perform a therapeutic/surgical procedure. (This may or may not occur in the same procedure room during the same session/encounter.) For example, diagnostic cardiac angiography leads to therapeutic angioplasty.

Modifier to use: XU Modifier versus 59

Depending upon your specific circumstances XU or 59 may be most appropriate.

Benign skin lesion (0.7 cm) removed from left posterior ribs (11401) and benign skin lesion (0.4 cm) removed from right arm (11400-59).

Modifier to use: 59

Rationale:  Same encounter
 Same organ system and/or
structure (skin)
 Different lesions.

Diagnostic mediastinoscopy via midline incision (39400) and thoracoscopy of right lateral lung via lateral incision with biopsy of pleura (32609-XS??). Different organ system (e.g. laparoscopy on separate organ systems).

Modifier to use: 59

Rationale:  Same encounter
 Same organ system
(respiratory)
 Different incision.

Colonoscopy with snare removal of polyp in transverse colon (45385) and bipolar cautery of polyp in descending colon (45384-59).

Modifier to use: 59

Rationale:  Same encounter
 Same incision or orifice
(rectum)
 Different/separate lesions.

Paired Structures, Ipsilateral versus Contralateral
“It is very important that NCCI-associated modifiers only be used when appropriate. In general these circumstances relate to separate patient encounters, separate anatomic sites or separate specimens. (See subsequent discussion of modifiers in this section.) Most edits involving paired organs or structures (e.g., eyes, ears, extremities, lungs, kidneys) have modifier indicators of “1” because the two codes of the code pair edit may be reported if performed on the contralateral organs or structures. Most of these code pairs should not be reported with NCCI-associated modifiers when performed on the ipsilateral organ or structure unless there is a specific coding
rationale to bypass the edit. The existence of the NCCI edit indicates that the two codes generally cannot be reported together unless the two corresponding procedures are performed at two separate patient encounters or two separate anatomic locations. However, if the two corresponding procedures are performed at the same patient encounter and in contiguous structures, NCCI-associated modifiers generally should not be utilized.” 

Different Procedure or Surgery
“One of the common misuses of modifier 59 is related to the portion of the definition of modifier 59 allowing its use to describe “different procedure or surgery”. The code descriptors of the two codes of a code pair edit consisting of two surgical procedures or two diagnostic procedures usually represent different procedures or surgeries. The edit indicates that the two procedures/surgeries
cannot be reported together if performed at the same anatomic site and same patient encounter

The provider cannot use modifier 59 for such an edit based on the two codes being different procedures/surgeries. However, if the two procedures/surgeries are performed at separate anatomic sites or at separate patient encounters on the same date of service, modifier 59 may be appended to indicate that they are different procedures/surgeries on that date of service.” 

Different Diagnosis
“Use of modifier 59 to indicate different procedures/surgeries does not require a different diagnosis for each HCPCS/CPT coded procedure/surgery. Additionally, different diagnoses are not adequate criteria for use of modifier 59. The HCPCS/CPT codes remain bundled unless the procedures/surgeries are performed at different anatomic sites or separate patient encounters.” 

Different Organs/Contiguous Structures
“From an NCCI perspective, the definition of different anatomic sites includes different organs or different lesions in the same organ. However, it does not include treatment of contiguous structures of the same organ. For example, treatment of the nail, nail bed, and adjacent soft tissue constitutes treatment of a single anatomic site. Treatment of posterior segment structures in the ipsilateral eye constitutes treatment of a single anatomic site. Arthroscopic treatment of a shoulder injury in adjoining areas of the ipsilateral shoulder constitutes treatment of a single anatomic site.”

“If multiple bacterial blood cultures are performed, including isolation and presumptive identification of isolates, code 87040, Culture, bacterial; blood, aerobic, with isolation and presumptive identification of isolates (includes anaerobic culture, if appropriate), should be used to identify each culture procedure performed. Modifier 59 should be appended to the additional procedures performed to identify each additional culture performed as a distinct service.” 

Relationship of Modifiers XE, XP, XS, and XU to Modifier 59
“These modifiers, collectively referred to as -X{EPSU} modifiers, define specific subsets of the -59 modifier…The -X{EPSU} modifiers are more selective versions of the -59 modifier so it would be incorrect to include both modifiers on the same line.” (CMS 4)
“Only if no more descriptive modifier is available, and the use of modifier 59 best explains thecircumstances, should modifier 59 be used.” (AMA 1)

References:

https://www.modahealth.com/pdfs/reimburse/RPM027.pdf